Background

The Centers for Medicare & Medicaid Services (CMS) was recruiting Medicare quality
improvement organizations (QIOs) to pilot new methods of transitioning patients from
inpatient to post-acute care. Led by Qualis Health, the local QIO, this Washington
hospital and community volunteered to participate.

As part of the new pilot, the QIO brought in experts to provide training in Eric Coleman's
Care Transitions Intervention coaching model, which focuses on managing medications,
educating patients about “red flag” symptoms, ensuring follow-up care,
and maintaining personal health records. “We recruited 40 various providers
in the first year of the project, including home health agencies, Medicare Advantage
Plan case managers, parish nurses,” said Selena Bolotin, a clinical social
worker and manager of the pilot program.

These trainees made changes to their existing practices based on the education, but
the pilot's leaders wanted to expand the program. They decided to recruit some community
volunteers to be trained as transition coaches.

How it works

Volunteers are recruited through a community volunteer center and a nearby university.
“While a number of our volunteers are retired nurses or have had some health
care experience, we've also had lay volunteers,” said Ms. Bolotin. “Because
it's not case management, it's not clinical care, [the program] allows a lay person
who learns the model to be able to coach and empower patient and family members around
self-management.”

After training, which includes 12 hours in the classroom plus on-the-job shadowing,
volunteers begin by meeting with a patient (Medicare beneficiaries who are considered
high-risk for readmission) in the hospital shortly before discharge. Then soon after
discharge, the volunteer visits the patient at home. “A lot of the home visit
is around medication management, but also checking in again on that follow-up visit
with the physician,” said Ms. Bolotin. Volunteers ensure that patients have
scheduled timely follow-ups, role-playing the conversation to have with a primary
care office receptionist, if necessary. They also review medications, red flags and
the personal health record.

Over the next few weeks, the volunteer calls the patient three more times, to make
sure the transition is going well.

Results

It's difficult to measure the impact of the program on readmissions to date, but the
anecdotal evidence, and preliminary tracking of individual patients, looks positive.
One patient had been hospitalized nine times in 13 months, but was able to stay out
of the hospital for the next seven months after the intervention.

Some intermediate process measures collected by the project are also showing its effect.
The coaching sessions have uncovered an average of 2.23 medication discrepancies per
patient. The program also assesses patient activation before and after coaching, and
has found that 75% of patients show greater engagement in their own care after the
intervention.

Challenges

Patient information and privacy were problems at first. Now, all volunteer coaches
attend the hospital's usual volunteer orientation, during which privacy regulations
are explained.

How others benefit

Volunteers, as well as patients, have been pleased with the interactions. “They
get to have genuine interactions with patients and family members that make a difference,”
said Ms. Bolotin.

Physicians who treat the coached patients, both in the hospital and out, have also
reported benefits. “One example of that had to do with a complicated dosing
protocol for a patient,” said Evan Stults, Qualis' executive director of communication.
“When the patient got the prescription, the hospital staff and the physician
thought it all made sense. But the patient went home and then the coach learned that
the patient did not know what she was supposed to be doing. The coach went back to
talk to the physician, and that was an eye-opener for the physician.”

Some outpatient docs have found interactions with patients to be more productive post-coaching,
and others have appreciated the reminder of the value of patient education. “One
physician said, ‘Wow, I should be asking all my patients if they know what
the red flags are and talking about that,’” Ms. Bolotin said.

Next steps

CMS funding for the pilot ends in July 2011, but the program's steering committee
is studying ways to sustain the intervention. “We are working actively with
the Area Agency on Aging and the local university to consider the benefits of integrating
the coaching program into case management services for seniors and providing a unique
student experience,” said Ms. Bolotin.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.